Knowing who your patients are
Practices participating in the Primary Care VBP model should anticipate that payers will:
- Attribute all patients to primary care practices based on a specific, pre-determined algorithm, starting with patient choice and then considering data on past utilization, if any, and consistent with Attribution Principles to foster alignment and transparency.
- Monitor the percentage of primary care services delivered to attributed members outside the primary care practice and inquire of outlier practices.
- Provide a general description of the PMPM rate methodology to primary care practices, ideally using a common template, including at a minimum:
- risk adjusting prospective primary care capitation payments and infrastructure payments based on age and sex.
- use of separate clinical risk methodologies for adults and pediatric populations using a validated methodology specific to that population, as available.
- use of clinical risk adjustment when measuring practices on TCOC and for at least certain infrastructure payments such as those that entail care management and other services involving support for patients with higher medical complexity.
- parameters for risk-adjustment, including ensuring a limited amount of variance on payout amounts based on a practice panel’s risk scores.
- adjusting PMPM amounts to reflect patient cost-sharing obligations.
- Annually update PMPM capitation rates and potentially modify requirements and services provided by primary care practices.
Learn more about member attribution in Section I Step 5 Understand member attribution and assignment.